Impact of the COVID-19 Pandemic on Saudi Parents’ Perceptions Toward Their Children’s Oral Health: A Cross-Sectional Study

Background The coronavirus disease 2019 (COVID-19) markedly affected all aspects of life. Pediatric dentistry and oral health of children faced a challenging situation during the pandemic. Aim This study aimed to assess the attitude of Saudi parents toward their children's oral health and dental treatment during the COVID-19 pandemic. Methods This online-based cross-sectional study was conducted using a structured questionnaire adopted from previous studies with some modifications. It was distributed among 385 Saudi parents recruited through social media. It included questions regarding demographic data, parents’ attitudes toward their children's dental care and dental visits during the COVID-19 pandemic, their fear level and willingness to take their children to dental appointments, and the parent’s perception of dental clinics with regard to the COVID-19 spread. Descriptive statistics and the chi-square test were used; statistical significance was set at a p-value < 0.05. Results Different levels of fear of the pandemic were expressed by Saudi parents, with 42 (10.9%) showing maximum fear while 36 (9.3%) reported no fear. Although about half of the parents stated that their children experienced dental pain during the pandemic, only 97 (25.1%) looked for dental care and were assisted. There was a significant association (p < 0.05) between the fear level with the family income and parents’ willingness to take their children to dental appointments. Conclusions COVID-19 has had a great impact on parents’ attitudes towards their children's oral health. A high percentage of Saudi parents' stated that they would take their children to dental clinics during the pandemic only for urgent treatment and severe pain.


Introduction
On March 11th, 2020, the coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization (WHO) [1].The highly contagious virus spreads rapidly through respiratory droplets expelled by infected individuals or from contact transmission with contaminated objects [2].Thus, dentistry practice and dental clinics are considered high-risk settings for viral transmission among patients and dental personnel [3,4].
To combat the spread of COVID-19, most governments, including the Kingdom of Saudi Arabia, set control measures such as lockdowns, curfews, social distancing, and quarantine.Although the incidence of COVID-19 in Saudi Arabia increased and decreased, the statistics showed remarkable control.This is attributed to the committed governmental efforts and the disciplined attitude of the public [5].
Suspension of schools and outdoor activities and increased time at home have led to alterations in the lifestyle and health behaviors of children [4][5][6].Subsequently, changes in dietary habits and oral hygiene practices occurred, and access to dental care was greatly compromised [6][7][8].Henceforth, pediatric dentistry faced a challenging situation that compromised the oral health of children [6,[9][10][11][12].
Moreover, the concerns regarding the safety of both dental practitioners and patients have led to a decrease in routine professional dental care [12][13][14].Fear of the pandemic has greatly influenced even the use of emergency dental services [15].It is only natural that the concerns of parents regarding COVID-19 are remarkably high when it comes to their children.However, as parents play a crucial role in the oral health of their children, their perception of COVID-19 was reported by some authors to have a negative impact on their children's oral health and oral care [13,16,17].
Thus, this study aimed to assess the attitude of Saudi parents toward their children's dental treatment and care during the COVID-19 pandemic, their fear level, their willingness to take their children to dental appointments, and their confidence level in the dental clinics after learning that the clinics had taken protective measures.

Ethical considerations
The Ethical Committee of the Dental Research Center at Qassim University (Saudi Arabia) approved this study (EA/F-2020-5003).All participants were requested to agree to the informed consent attached with the questionnaire before being included in the current study.

Study design
The study was conducted at College of Dentistry, Qassim University, Saudi Arabia.It is an online questionnaire-based cross-sectional study that was conducted from November 2020 to January 2021 during the second wave of the COVID-19 pandemic.

Sampling and study participants
The sample size was calculated, using a 95% confidence level and a margin of error of 5%, as a minimum of 385 respondents.
A convenient snowball-sampling technique was used to recruit participants via social media platforms of the Saudi population.Google Form link and invitations to participate in the study were distributed using the investigators profiles in WhatsApp (Meta Platforms, Inc., Menlo Park, California, United States), Twitter (Twitter, Inc., San Francisco, California, United States), Telegram (Telegram, Dubai, United Arab Emirates), and Instagram (Meta Platforms, Inc., Menlo Park, California, United States).The responding participants were then requested to spread invitations to their contacts.
Inclusion criteria were Saudi parents (fathers or mothers) of at least one child less than 12 years of age, parents of healthy children with no special health care needs, parents consenting to participate, and parents who had an account on social media.Parents of nationalities other than Saudi and those with special health care needs children were excluded.

Data collection
A self-administered structured questionnaire was designed based on previous studies [13,18] with some modifications.The questionnaire was translated from English to Arabic and then back translated to ensure accuracy.The pre-final Arabic version of the questionnaire was then pilot-tested to check its reliability among 38 parents (10% of the sample size) who were not included in the main study.The final version of the questionnaire is shown in Appendix 1.
After consenting, the participants answered 14 questions regarding socioeconomic and demographic data, including the parent's age, relationship to the child (mother or father), number of children in the family, educational level of the parent, and family income.In addition, participants were asked to assess their fear level of the pandemic in an ascending order from 0 to 5. Other questions comprise parents' perceptions towards their children's oral health and dental visits during the COVID-19 pandemic and their confidence toward the protective measures taken by the dental clinics to reduce COVID-19 spread.

Statistical analysis
The statistical analysis was performed using the IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States).Descriptive statistics (frequencies, percentages, means, and standard deviations) were done for the different variables in the study.The chi-square test was used to assess the association among different categorical variables in the study.A p-value of less than 0.05 was considered to be statistically significant.

Results
A total of 387 participants responded to the questionnaire; the majority were mothers (n=296) compared to 91 fathers.Demographic data on parents' age and level of education, number of children, and family income are shown in Table 1.

FIGURE 1: Fear level of the pandemic.
Nearly half of the parents (n=183, 47.3%) stated that they would take their children to dental appointments only for urgent treatment and severe pain, while 72 (18.6%) would not take them at all.Among the latter group, the main reason, according to 44 (11.4%) parents, was fear of contracting the COVID-19 virus (Figure 2).

Data are presented in numbers and percentages (%).
There was no significant association between the fear level and any of the demographic data (parents' age, their level of education, number of children in the family).However, a significant association (p<0.05) was noted between the fear level and the participating parent (father or mother), the family income, and parents' willingness to take their children to dental appointments (Table 4).

Discussion
The spread and consequences of COVID-19 varied considerably across different countries, leading to subsequent variations in responses and attitudes of the communities.In Saudi Arabia, this was governed by factors such as population size, urban growth, infrastructure, and economic status.The spread of COVID-19 in Saudi Arabia had initially prompted panic responses in the society.However, the measures created by the public health system combined with good community compliance had provoked effective control of the pandemic [5].
Dental care was greatly compromised due to the high hazards of viral transmission in dental clinics.More than other times, the general and oral health of children depends largely on their parents' beliefs and attitudes.
The results of the current study showed that many parents are limited looking for professional dental care for their children.Besides that, a considerable number of parents stated they were looking for dental care for varied reasons (pain, trauma, and caries) but were not assisted.The data obtained are broadly consistent with the trends of other studies [13,[19][20][21].On the contrary, in a study from China [18], the majority of parents (83.78%) stated they would take their children to dental clinics in cases of severe pain.Limiting or deferring the provision of professional pediatric dental care was an unavoidable precaution during the pandemic, in spite of its expected unfavorable consequences for immediate and future oral health [22].
Many reports and guidelines worldwide emphasize that attending a dental clinic poses an extra risk of COVID-19 transmission through aerosol generation during many dental procedures [23].Surprisingly, different studies have shown apparent variations in the perceptions of participants regarding this issue.The findings of the current study state that just about a quarter of the participants (27.4% of parents) thought that dental clinics constitute more danger than other public places.Similar findings were reported in other studies from Saudi Arabia (36%) [24] and Turkey (34%) [25].These rather low percentages might indicate insufficient awareness among the public about how the COVID-19 virus might be transmitted in dental clinics and accordingly highlight the need for more educational programs.On the contrary, other studies reported higher awareness; 53% of participating parents in India [26] and 66% in China [18] thought the dental environment could be more dangerous than other environments.However, the high confidence level about protective measures taken by dental clinics reported in the current study (87.1%) is consistent with another study in China (81%) [18].Alternatively, other studies show lower levels of confidence.A study from Saudi Arabia [24] reported that more than half of participating parents had little or no confidence in the infection control measures taken at dental offices.Similarly, 46% of the respondents in an Indian study showed confidence in the preventive measures of dental departments [26].
In the current study, various levels of fear of the pandemic were expressed by the participants, with 10.9% showing maximum fear.These findings are consistent with prior studies that noted variable levels of fear.In a study in Brazil [13], 16.1% of participants declared high levels of fear; another study in India [27] reported that 64% had high fear levels.While this might seem normal, the high levels of fear might cause people to have unreasonable thoughts regarding many issues; their children's oral health is no exception.A significant association between the fear level and the parent's willingness to take their children to dental clinics was noted in the current study; about half of the parents with the highest level of fear (score 5) would not take their children to dentists.This was consistent with other studies from Brazil [13], India [16], Italy [28], and Saudi Arabia [24].These results reflect that the COVID-19 pandemic might lead to an increase in unmet treatment needs and thus negatively affect the oral health of children.Limited research has compared the pre-and post-dental status of children; a study from Greece [29] revealed more carious lesions and significantly increased treatment needs after the lockdown.
The present study highlights important clues about the favorable and unfavorable attitudes of parents regarding their children's oral health during the disturbed period of the pandemic and thus provides a path to improve educational programs.Further implementation of alternative tools, such as teledentistry, might be useful in the future.This can be achieved by remote parents' education regarding not just general oral hygiene.It is also necessary to put more emphasis on topics such as home care, infection control, and modes of transmission of the COVID-19 virus.Furthermore, the public needs education about dental emergencies and the importance of professional intervention in such cases while maintaining strict protection protocols.
The current study has some limitations, such as the relatively small sample size.Furthermore, the data collected via an online questionnaire might be a potential bias since the findings might not be representative of a sector of parents with no social media accounts who might stand for certain educational or socioeconomic levels.Another limitation is the subjectivity of some of the questions, such as the socioeconomic status and dental caries being noticed by parents.However, a community-based sampling technique would not have been possible because of the social distancing and lockdown measures during the study period.

Conclusions
This study provides additional evidence that COVID-19 had a significant impact on parents attitudes towards their children's oral health.About half of the Saudi parents in the current study stated that they would take their children to dental clinics during the pandemic, only for urgent treatment and severe pain.A considerable number of parents expressed fear of the pandemic; this was significantly associated with

FIGURE 2 :
FIGURE 2: Parents' willingness to take their children to dental appointments during the pandemic.

TABLE 1 : Demographic distribution of data.
Data are presented in numbers and percentages (%).No Yes, I

Table 3
illustrates the parents' views for dental treatment and dental clinics with regard to COVID-19 spread.Only 106 (27.4%) parents thought that the environment of the dental departments was more dangerous than that of other public places.The majority of parents (n=337, 87.1%) reported having confidence in dental treatment after learning that dental clinics had taken protective measures.Parents'